Nokea
An elderly patient comes into the emergency department complaining of an earache. The patient has an oral temperature of 100.2 F and otoscopic assessment of the ear reveals a pearly gray tympanic membrane with no evidence of discharge or inflammation. Which action should the triage nurse take next?
- A. Palpate the patients parotid glands to detect swelling and tenderness.
- B. Assess the temporomandibular joint for evidence of a malocclusion.
- C. Test the integrity of cranial nerve XII by asking the patient to protrude the tongue.
- D. Inspect the patients gums for bleeding and hyperpigmentation.
Correct Answer: A
Rationale: Older adults and debilitated patients of any age who are dehydrated or taking medications that reduce saliva production are at risk for parotitis. Symptoms include fever and tenderness, as well as swelling of the parotid glands. Pain radiates to the ear. Pain associated with malocclusion of the temporomandibular joint may also radiate to the ears; however, a temperature elevation would not be associated with malocclusion. The 12th cranial nerve is not associated with the auditory system. Bleeding and hyperpigmented gums may be caused by pyorrhea or gingivitis. These conditions do not cause earache; fever would not be present unless the teeth were abscessed.
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A nurse is assessing a patient who has just been admitted to the postsurgical unit following surgical resection for the treatment of oropharyngeal cancer. What assessment should the nurse prioritize?
- A. Assess ability to clear oral secretions.
- B. Assess for signs of infection.
- C. Assess for a patent airway.
- D. Assess for ability to communicate.
Correct Answer: C
Rationale: Postoperatively, the nurse assesses for a patent airway. The patients ability to manage secretions has a direct bearing on airway patency. However, airway patency is the overarching goal. This immediate physiologic need is prioritized over communication, though this is an important consideration. Infection is not normally a threat in the immediate postoperative period.
A nurse is caring for a patient who is acutely ill and has included vigilant oral care in the patients plan of care. Why are patients who are ill at increased risk for developing dental caries?
- A. Hormonal changes brought on by the stress response cause an acidic oral environment
- B. Systemic infections frequently migrate to the teeth
- C. Hydration that is received intravenously lacks fluoride
- D. Inadequate nutrition and decreased saliva production can cause cavities
Correct Answer: D
Rationale: Many ill patients do not eat adequate amounts of food and therefore produce less saliva, which in turn reduces the natural cleaning of the teeth. Stress response is not a factor, infections generally do not attack the enamel of the teeth, and the fluoride level of the patient is not significant in the development of dental caries in the ill patient.
A nurse is providing oral care to a patient who is comatose. What action best addresses the patients risk of tooth decay and plaque accumulation?
- A. Irrigating the mouth using a syringe filled with a bacteriocidal mouthwash
- B. Applying a water-soluble gel to the teeth and gums
- C. Wiping the teeth and gums clean with a gauze pad
- D. Brushing the patients teeth with a toothbrush and small amount of toothpaste
Correct Answer: D
Rationale: Application of mechanical friction is the most effective way to cleanse the patients mouth. If the patient is unable to brush teeth, the nurse may brush them, taking precautions to prevent aspiration; or as a substitute, the nurse can achieve mechanical friction by wiping the teeth with a gauze pad. Bacteriocidal mouthwash does reduce plaque-causing bacteria; however, it is not as effective as application of mechanical friction. Water-soluble gel may be applied to lubricate dry lips, but it is not part of oral care.
A patients neck dissection surgery resulted in damage to the patients superior laryngeal nerve. What area of assessment should the nurse consequently prioritize?
- A. The patients swallowing ability
- B. The patients ability to speak
- C. The patients management of secretions
- D. The patients airway patency
Correct Answer: A
Rationale: If the superior laryngeal nerve is damaged, the patient may have difficulty swallowing liquids and food because of the partial lack of sensation of the glottis. Damage to this particular nerve does not inhibit speech and only affects management of secretions and airway patency indirectly.
A patient seeking care because of recurrent heartburn and regurgitation is subsequently diagnosed with a hiatal hernia. Which of the following should the nurse include in health education?
- A. Drinking beverages after your meal, rather than with your meal, may bring some relief.
- B. Its best to avoid dry foods, such as rice and chicken, because theyre harder to swallow.
- C. Many patients obtain relief by taking over-the-counter antacids 30 minutes before eating.
- D. Instead of eating three meals a day, try eating smaller amounts more often.
Correct Answer: D
Rationale: Management for a hiatal hernia includes frequent, small feedings that can pass easily through the esophagus. Avoiding beverages and particular foods or taking OTC antacids are not noted to be beneficial.